Endocrine Abstracts

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome and is tightly associated with type 2 diabetes (T2DM), the principal risk factor for disease progression, liver failure and cardiovascular complications. At present there are no licensed therapies and management aims to optimise metabolic risk factors through weight loss, and pharmacological interventions for diabetes and cardiovascular disease. A multidisciplinary approach involving hepatologists and diabetologists working alongside allied health professionals providing structured lifestyle advice is advocated, although objective evaluations of this approach are currently limited.

Objective: We have undertaken a retrospective study to determine the impact of a large, tertiary centre, multidisciplinary metabolic hepatology clinic. Detailed liver, cardio-metabolic and related health parameters including surrogate markers of metabolic syndrome, cardiovascular risk and liver disease were evaluated in addition to a pilot health economic analysis.

Results: 165 patients with NAFLD without hepatic co-morbidities and excluding those undergoing bariatric surgery, were followed from referral until latest review. All patients attended ≥2 times between 2014 and 2017. Median follow-up period was 13 months (2–34). At baseline, 29% had liver cirrhosis and 59% had T2DM. At follow-up, weight decreased by 3.3 kg (3.4%, P=0.0005) and was associated with significant improvements in liver chemistry (alanine aminotransferase, ALT: −11 IU/l, 21%, P<0.0001), and total cholesterol (−0.7 mmol/l; 14%, P=0.0023). Median HbA1c fell (1.5 mmol/mol, 3.1%, P=0.0045), with reduction most marked in those with poorly controlled T2DM (HbA1c >58 mmol/mol at baseline: −14 mmol/mol, 18%, P<0.0001). Overall, there was a 6.4% reduction in 10-year cardiovascular risk (QRISK3, aged-match, P=0.0085). Finally, median liver stiffness, measured using transient elastography as a surrogate of fibrosis, decreased by 1.3 kPa (14%, P=0.0097). Preliminary economic analysis of our multidisciplinary approach using the UKPDS Outcomes Model indicated an improvement in quality adjusted life expectancy alongside a reduction of costs of diabetes complications if health improvements were maintained. Importantly, these costs fell well below the accepted UK cost-per-QALY (quality adjusted life year) threshold of £20,000 for commissioning of health interventions, suggesting a cost-effective clinical management strategy.

Conclusion: Our results demonstrate that patients with NAFLD managed through a multidisciplinary approach derive significant clinical improvements in liver and cardio-metabolic health. Patients with poorly controlled T2DM, demonstrated the largest improvement in HbA1c of a magnitude known to reduce complications which may potentially confer good benefit to patients in slowing NAFLD progression. Furthermore, our pilot economic data suggest that this approach may also be cost-effective.